At Cherokee Health Systems (CHS), a federally qualified health center which provides integrated primary care to the underserved in East Tennessee, the prevalence of overweight and obesity in children aged 4 to 10 years is approximately 42% and over 50% of households with children receiving care at CHS are food insecure. Thus, these children are at high risk for experiencing health disparities later in life. Implementing Prevention Plus (PP) is recommended for childhood obesity treatment within a primary care setting. We have evaluated PP to determine the best combination of energy balance behaviors, and frequency and mode of contact over 6 months, to optimize reductions in standardized body mass index (zBMI) in children aged 4 to 10 years. Our PP program has reduced zBMI to a degree that should improve cardiometabolic health in young children, which is important in addressing health disparities. However, the ability of this program to improve weight status when delivered by primary care providers to underserved children is unknown. As household food insecurity is so prevalent with CHS families, a family-based approach, in which energy balance behavior goals are provided to both caretaker and child, may reduce overall family adherence and program satisfaction, as female caretakers in food insecure households may feel less comfortable meeting their own dietary goals while participating in an intervention for their child, or may be concerned with the degree of change required in purchasing food perceived as more costly when multiple family members have dietary goals. Not addressing these concerns may reduce overall effectiveness of the program in CHS. Thus, the aim of this application is to conduct a randomized controlled trial examining our PP program implemented through the electronic health record (EHR) and delivered by CHS primary care providers, Behavioral Health Consultants, on child zBMI in underserved children who receive their primary care at CHS and who are overweight and obese. Furthermore, we will explore the moderating effect of household food security status on our PP program delivered with and without caretaker goals. Sixty food secure and 60 food insecure families from CHS, with a female caretaker and a child aged 4 to 10 years who is > 85th percentile BMI, will be randomized to 1 of 3, 6-month conditions: 1) Newsletter; 2) PP with caretaker energy balance behavior goals (PP+); and 3) PP without caretaker energy balance behavior goals (PP-). The primary aim is to determine if: 1) at 6 months, children in PP+ and PP- will have a lower zBMI than Newsletter; and explore if: a) in food secure households, if PP+ produces a lower child zBMI than PP-; and b) in food insecure households, if PP- produces a lower child zBMI than PP+. Data extraction from the EHR will provide information about program implementation and delivery and comparisons will be made on child and caretaker diet and activity and caretaker program satisfaction to better understand potential mechanisms by which household food security status may moderate outcomes.